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a Gk <br /> ORIGINAL STATE OF CALIFORNIA G Do not fill in <br /> ie vrith DWR THE RESOURCES AGENCY n� <br /> DEPARTMgNT OF WATER RESOURCES No. 096677 <br /> ' of latent No � _ WATER WELL DRILLERS REPORT State Welt No e� <br /> .remit So or Dat <br /> / Other Wall No_ __- <br /> Ad O SQR=4 ,jam l 12) WELL LOG Total dept s�f Depth of completed wetLLwL'�ft <br /> Ad `7 i,v j! a from ft to ft Formation (Descnbe by color, character size or material) <br /> City Zi r <br /> (2) TIO OF WELE (seeinstructio � <br /> County Owner's Well um1) r �--mt <br /> Well address different from ah ^�' 1 a . Za <br /> Townshf �+�—Range sectio — <br /> Distance from cities, a railroads,fences,etc – <br /> r7 7 <br /> (3) TYPE O3iWORK <br /> Na- wen Decwning ❑ <br /> A9 47 <br /> Reconstruction ❑ — <br /> Rocgnditloning 13 <br /> Horizontal Watf © , <br /> Destruction 0 (Describe <br /> destruction materials wo <br /> b proceduresin Itcat <br /> (4) PROPOSED AN <br /> Domestic <br /> irrigation ❑ <br /> IndustrltJ Q — <br /> ' T Wen ❑ <br /> .S u Stoc <br /> Mwricip — <br /> 1t LL LOCATION SKETCH �/ Other ❑ — <br /> (5) EQUIPbfENTr (ti) GRA ACK: <br /> Rotary EL., Reverse © No Si <br /> Cable 0 Air ❑ � t r of I— — <br /> Other 0 Socket f7 �L <br /> (7) CASING INSTAC.LB (B) ERFORA – <br /> Steel p Plastic 7Co fee' Typa of pe ar a of scree <br /> Fmm To Dia G o'a Fr To <br /> ft ft fn Wall ft ft < i <br /> I <br /> (9) WELL SEAL: p� <br /> %Vru surface sanitary seal providad? Yes No 0 If yes, to depth �t_/�t <br /> Were strata seated against pollutiCY4 Yes l No❑ Interval _ it – <br /> Method of sealin work start lS Complet l9 <br /> (10) WATER LEVELS WELL DRnLWS STATEMENT, <br /> Depth of first water, if know — This aeon was r It <br /> d wade mu i ci <br /> Standing level after well euro letio f� • ft knowlerfge and f( , v elf jg <br /> #reyore is rrue to the beat o/ mg <br /> (1z) WELL xEsrs. s1� <br /> Was well test made? Yes ❑ No if yes, by wham? — a C , R <br /> Type of test Pump ❑ Sailer❑ Air lift C1 WAM j 4 <br /> Depth to water at start of test ft_ At end of festit 'r ' g thy pr#'t�rl <br /> rSe_--"gal/min after Wator tomperalw Address 4 r `4`4 } <br /> ,d analysis made? Yes C] Na ryl, <br /> es, by whom? sib ! <br /> as alectnc Io! made? Yes ❑ Noes,attach copy to this report License nato of thisrropp ` <br /> OwR 1138 (RMV 7 78) IF AMDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBE�RP-0 p0}IM <br />